by Paul Giblin and Rebekah L. Sanders, The Arizona Republic

by Paul Giblin and Rebekah L. Sanders, The Arizona Republic

PHOENIX -- Minutes before offering his resignation Friday, Veterans Affairs Secretary Eric Shinseki presented President Barack Obama with a damning audit that paints the VA health-care system as bound by unrealistic expectations and a culture that pressures appointment schedulers to falsify data tied to performance bonuses.

The internal audit of the VA's largest hospitals and community-based clinics echoes a separate inquiry released earlier in the week that prompted mounting calls for Shinseki's ouster.

"The misconduct has not been limited to a few VA facilities but many across the country," Obama said as he announced his acceptance of the secretary's resignation. "That's totally unacceptable.... I said that if we found misconduct, it would be punished. And I meant it."

The reviews and the resulting firestorm that has spread from Phoenix to Washington was sparked in April by a whistle-blower, Dr. Sam Foote, a former Phoenix VA physician. He described to The Arizona Republic and congressional leaders improper scheduling schemes and secret lists that caused veterans to wait months for medical appointments. Foote said at least 40 patients may have died while waiting for care.

Bolstering Foote's allegations, the audit released Friday found that meeting a 14-day wait-time performance target for new appointments was not attainable because of struggles to hire enough health-care providers to meet a growing demand for service.

In some cases, schedulers were pressured to make wait times appear more favorable. Auditors called such practices pervasive and urged the VA to "re-examine its entire performance-management system."

Friday's report comprised the audit's first phase, covering most of the VA's largest hospitals and community-based outpatient clinics, which together represent 258 points of access. The forthcoming second phase will cover the remaining facilities.

Obama said the consequences for any misconduct would include firing senior leaders at the Phoenix VA and canceling this year's performance bonuses. The VA is working to contact every veteran waiting for care in Phoenix to schedule appointments even if it means sending them to private providers.

"Everybody who's out there waiting, get them an appointment," Obama said.

He pledged to hire doctors and nurses and to upgrade equipment, including computers that date to the 1990s. He urged a culture change to encourage transparency. And he said officials need to set more-achievable wait times. "Part of what we have to do is figure out what are realistic benchmarks for the system," he said.

Auditors determined that the highest barrier to timely access is a lack of appointment slots for medical providers to see patients.

There are other complications.

The computerized scheduling system is overly complicated and leads to confusion among clerks and front-line supervisors.

Schedulers also purposefully juked the system. Auditors found that 13 percent of scheduling personnel indicated they got instructions to input appointment dates in the "desired date" field that were different from the dates veterans preferred. It was not immediately clear why schedulers did so.

Also, 7 to 8 percent of schedulers indicated they used alternatives to the VA's electronic wait-list system.

Auditors recommended "rapid and definitive" changes to restore integrity to the system. They offered 19 recommendations, including elimination of the 14-day appointment goal, suspension of performance awards tied to wait times and face-to-face engagements with front-line personnel to reinforce the messages.

As the scandal deepened this week, U.S. Rep. Ann Kirkpatrick, D-Ariz., gathered signatures from 60 House members on both sides of the aisle for a letter that urged the agency to take ample time for a thorough review after the audit's first phase.

Shinseki's resignation angered retired Army medic Joseph Dimeco, 67, of Goodyear. He blamed the White House for scapegoating the former Army chief of staff.

"This is the man who was trained all his life to make sure that all five services ... got whatever they needed," Dimeco said. "He delivered food, guns, bullets, repair parts, water. Whatever they needed, he got it there on time."

If the retired general struggled to provide health care on time, he said, it was only because Congress tied his hands with red tape.

"He wasn't allowed to do this job," Dimeco said.

A veteran of Vietnam, Korea and the Persian Gulf, Dimeco waited two years for treatment of post-traumatic stress disorder and was told the VA could not cover a specialty medicine for heart problems.

He finally turned to his Defense Department insurance, Tricare, provided as a benefit for his nearly 20 years in the military, to pay for PTSD assistance from a private provider and drugs from Luke Air Force Base's pharmacy.

Despite the calls from Obama and Congress for reform, Dimeco is pessimistic.

"This is just a dog-and-pony show," he said. "Nothing's going to get fixed."